Provider Demographics
NPI:1568824670
Name:WAXMAN, DONALD W (MFT)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:W
Last Name:WAXMAN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 C ST
Mailing Address - Street 2:BODEGA
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-3025
Mailing Address - Country:US
Mailing Address - Phone:707-585-2334
Mailing Address - Fax:
Practice Address - Street 1:6 C ST
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-3025
Practice Address - Country:US
Practice Address - Phone:707-585-2334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-28
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49618106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$Medicare UPIN